Provider Demographics
NPI:1467119818
Name:BLACKWELL, MELISSA M (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 BOUNTIFUL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-8819
Mailing Address - Country:US
Mailing Address - Phone:970-368-0992
Mailing Address - Fax:
Practice Address - Street 1:424 KIMBARK ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5526
Practice Address - Country:US
Practice Address - Phone:303-427-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0014944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist